Open Letter from Brian Hepburn of NASMHPD


National Association of State Mental Health Program Directors




Today, DHHS Secretary Alex Azar addressed the National Association of Medicaid Directors and announced new opportunities for innovative service delivery system design focused on adults with serious mental illness (SMI) and children with serious emotional disturbance. The Centers for Medicare and Medicaid Services (CMS) also sent a letter to State Medicaid Directors with more detail, including an opportunity for short term residential treatment in IMDs using Medicaid funds within a demonstration project.


“Today, CMS will be sending a letter to state Medicaid directors laying out how to apply for waivers for flexibility … to treat serious mental illness. … [W]e will strongly emphasize that inpatient treatment is just one part of what needs to be a complete continuum of care, and participating states will be expected to take action to improve community-based mental health care. There are effective methods for treating the seriously mentally ill in the outpatient setting, which have a strong track record of success and which this administration supports. … Both tools are necessary and both are too hard to access today” Alex M. Azar II, November 13, 2018.


We applaud these strong efforts and want to draw particular attention to the focus on an accessible crisis continuum, which was also a key priority in the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) The Way Forward report to Congress and the NASMHPD Beyond Beds series of Technical Assistance Coalition Assessment Working Papers. The passage from the letter below is indicative of this focus:


Improved Access to Services Across the Continuum of Care Including Crisis Stabilization Services

Adults with SMI and children with SED need access to a continuum of care since these conditions are often episodic and the severity of symptoms can vary over time. However, the only treatment options in many regions are inpatient care for acute treatment needs and outpatient care for less serious conditions and on-going maintenance therapy, with little availability of intermediate levels of care. As a result, individuals with serious mental health conditions often go into inpatient facilities or emergency departments when they could be better served in community-based settings. Furthermore, without the supports needed to help transition from acute care back into their communities, adults with SMI are at heightened risk for relapse and readmission. Mental health disorders are often the primary cause of hospital readmissions among adult Medicaid beneficiaries, indicating a need for more evidence-based community-based supports and services.


Strategies for ensuring individuals with SMI or SED are provided appropriate levels of care to meet their needs include encouraging use of evidence-based assessment tools, e.g. the LOCUS and CASII (or CALOCUS), that link clinical assessments with standardized “levels of care” using methods for matching the two. It is also important that the care provided to individuals with SMI or SED is trauma-informed. Another strategy is to increase availability of intensive outpatient and crisis stabilization programs designed to divert Medicaid beneficiaries from unnecessary stays in emergency departments (EDs) and inpatient facilities as well as criminal justice involvement. Core elements of crisis stabilization programs include regional or statewide crisis call centers coordinating access to care in real time, centrally deployed mobile crisis units available 24 hours a day and seven days a week, and short-term, sub-acute residential crisis stabilization programs.


References from the Letter to State Medicaid Directors included:

  • National Association of State Mental Health Program Directors, “Issue Brief: Crisis Services’ Role in Reducing Avoidable Hospitalization” (Aug 2017)
  • National Action Alliance for Suicide Prevention, Crisis Services Task Force, “Crisis Now: Transforming Services Is Within Our Reach” (2016)
  • Interdepartmental Serious Mental Illness Coordinating Committee, Report to Congress, “The Way Forward: Federal Action for a System That Works for All People Living With SMI and SED and Their Families and Caregivers” (Dec 2017)



Brian Hepburn M.D.
Executive Director

Download the Letter